A Rare Type Of Dermatologist Who Practices Differently – The Eczema Podcast (S4E02)

 

There just wasn’t anybody who specialized in adult eczema because you basically had to say, I’m willing to take a 70% pay cut so that I can take care of really difficult patients so that I can go home at night, have trouble sleeping because I’m worried about the people that I saw and I feel bad for them. Whereas my colleagues who are taking care of skin cancer, acne works, rosacea, normal stuff, they’re not worried about their patients because they’re basically well and they make three or four times more than I do.

Hi everyone. Welcome to the eczema podcast today. I have a really great guest on the show today and his name is dr Matthew is Iris. He is a wealth of knowledge. He’s actually friends with Dr. Peter Lio and Dr. Jonathan Silverberg, both of who I’ve had on the show. So it’s actually pretty neat because I was talking to Matthew and he mentioned that they’re actually all really close. And they’re also one of their, actually one of the few experts in the States that actually specialize in dealing with patients who have eczema. So hi Dr. Matthew, welcome to the show.

Hello Abby. And I would give a little caveat there and say that we’re some of the very few dermatologists who specialize in adults with eczema. There are lots of people who specialize in kids with eczema, but for adults with eczema- Jonathan, Peter and I are probably three of the very small number of people who do that.

And while we were talking, you actually mentioned something about how you know, the, because you guys specialize in eczema, you guys actually earn four times less than regular dermatologist who could see a lot of different other patients.

And so I, I can’t speak necessarily for Jonathan and Peter, but I would assume that it’s actually very similar. So it’s one of the things that’s an interest in patients. Whenever they come to see me, we’ll often ask, you know, why hasn’t any other dermatologists sat down and spent 20 or 30 minutes talking to me about my eczema? And you do that every visit. And the reason is that, you know, most dermatologists, there’s so much demand for them to get seen, for patients to be seen. People want to come to get seen to get checked for skin cancer and to get their acne better and to you know, get their Botox and whatever. And so there’s so many people wanting to get in that they have to see patients very quickly and they see patients about every seven or eight minutes on average. And so they just don’t have the time.

If they spent 20 or 30 minutes with every patient, then people would have to wait, you know, a year to get in to see them, by which time your skin cancer could kill them. And so a normal dermatologist sees patients a lot faster than us. And second, they do a lot more procedures. So as a dermatologist, the majority of what you make, the majority of what you earn is based on procedures. So treating skin cancers, treating pre skin cancers, treating warts during surgical procedures. So for me, when I spend 20 or 30 minutes with a patient, I get paid here in the U S somewhere between 70 and a hundred dollars by their insurance company for spending that 20 to 30 minutes a normal dermatologist who’s going to see three to five patients in those 30 minutes and is voiding in in those three to five patients is probably going to do at least two or three biopsies in is going to a freeze.

Another two or three things that are, that are all of this related to skin cancer. When I make the 70 to a hundred dollars in that 30 minute, 20 to 30 minutes, they’re going to make about four or $500 in that 20 to 30 minutes. And so there’s really a significant penalty to me for caring about people with eczema, right? So I, I make much less, and I take care of patients that are much sicker. And so people who I go home at night and I’m worried about, Oh my gosh, that poor lady. How does she live like that? I feel so bad for her. Or, Oh my gosh, that you know, this person, I’ve tried this, this, this and this and none of it’s worked. What am I going to do next? I don’t know what to do and I can’t sleep at night because I’m thinking about these people. Whereas whenever I see what I would call regular dermatology patients, I know what they have. I know what to do about it. [inaudible] It’s much easier. And so you have to really be passionate about eczema to make it something that you want to specialize in.

And you were also mentioning to me that you, you even come up with like a plan, like a whole, you know, one or two page plan for the face.

Oh, it’s, it’s one of the things that, that often I, I forget how different I am from normal a dermatologist. So you’ll often hear the term eczema action plan and many dermatologists will have like a, a sheet that’s preprinted with a lot of instructions that they then, you know, check box. Okay, you’re going to do this. When you’re going to do that, when here’s these three moisturizers, you’re going to use, this one, you’re gonna put on this often. I cannot practice that way. So every patient is unique and every patient is so unique. That to, for me to have a sheet that listed all the different things I might tell them to do and then I could check it off, it would be 50 pages long and flipping through. Okay. Here on page 32, you’re going to do this, ignore from page 10 to 22 instead after I finish a visit with a patient, I say to them, ah, okay, now [inaudible] at the start of the visit I’ll say, don’t write anything down.

Just focused on talking to me, listening to me, telling me what you need to tell me, answering my questions because I’m going to write everything down for you at the end. And then at the end of the visit once I’ve, you know, really negotiated a plan with them because I’m a believer that it’s always a negotiation. Right? if I could tell, if I could just tell people what to do and they would do it, I would tell everybody, okay, move to Fiji and live on the beach. And you know, just sit there and don’t touch anything right in their eczema would do great. But people can’t do that. Right? So it’s, there’s the, here’s what I think, and then it’s, well maybe they’ve tried that before, maybe they’ve tried stuff similar to it. Maybe what I’m thinking they should do just isn’t doable because of they’re working for their family, whatever.

So it’s a negotiation. But once that’s all done and we’ve got a, and I’ve got a plan in my mind of what we’re going to do, next thing I say is, okay, so now I’m going to summarize exactly what I’m, what’s going on and what I want you to do, right? My phone has dragon, which is a transcription thing that you speak and in real time it is transcribing it into text. So I sit there in front of the patient, drag it on my phone and start to dictate. So it, it would go something like, okay, so you have eczema and eczema is caused by when your immune system overreacts against the environment and blah, blah, blah, blah. And then once I get through the, here’s what you got, here’s what’s going on, there’s going to be here. Okay, new paragraph. I recommend that you do the following numeral one period, you were going to get a moisturizer called blah.

It lifted it out and here’s how you’re going to use it, when you’re going to use it. How frequently. I’m numeral two, I’m going to prescribe a medication called black. Here’s what you were going to do with that. And so it, and they can interrupt me while I’m dictating. What did you mean by I thought you said it was going to be, stop the dictation. Okay. Now. And then as soon as I’m done with the dictation copy, paste it into their chart and my medical assistant prints it off for them. And so they walk out of my office with a completely individualized, completely unique, here’s what you, so if you were a patient, here’s Abby’s unique. Only plan like this in the entire world for her eczema. No, I, I kind of hesitate to tell people that that’s what I do because I do, you know, if I was a patient, I’d be like, that’s what I want. And I, you know, I, you can only see so many patients. So that’s what I do with all of my patients.

I’ve actually never heard of that before. That’s so smart to do the transcription thing. So what gave you the idea to do that?

So my well that’s sort of a long answer and let me, let me take you kind of back to how I got into doing eczema, because that’s where the answer starts. So when I was a resident in dermatology, six months into being a resident, I realized that I knew as much about treating eczema as the absolute top experts in the world. And right it was doves, avoid wearing wool. Don’t get too hot, don’t take hot showers, use dove bar. So I use a moisturizer, use a Blandy Malian and here’s a jar of trying to send a loan, an ointment to put on twice a day for two weeks on and take one week off. [inaudible] Oh, and here’s some hydroxizine to help with the itching to help you sleep at night. And then what I learned at the same time was I also, as I was walking out of that room with my supervising physician, I wanted to like poke my head back in the door and say, Oh, by the way, none of this is going to work.

Because it didn’t, right. That was the same thing. Every other dermatologists they had seen for the last 20 years of their life had told them the exact same stuff. It had never worked. They told us it didn’t work and then we told them to keep doing the same stuff. Right. And so then the, you know, the next thing we would talk about using systemic steroids and systemic immunosuppressants like methotrexate or cycle score and these medications that just suppress your immune system in general and they work okay. They are certainly much more effective than, than the normal creams and topicals. But they still didn’t work on that good either. And so I’m somebody who likes to figure stuff out. So being a naive resident in dermatology and not knowing anything, I was like, I bet I can figure out how to help these people.

I bet I can come up with what is really driving their eczema. And so I got into doing patch testing. So, which is testing, looking for, are there specific ingredients that somebody’s immune system has started to react against? Right? So you can start to have a problem with the, a preservative in your moisturizer with the emulsifiers and your, the moisturizer you’ve used for 20 years, you could suddenly become allergic to it. So my first thought as a resident was maybe we’re missing a lot of these allergies and they started to have problems from their soaps and their moisturizers and their premiums. So I’m going to start growing this patch testing and that, that became one of the primary things that I do as a dermatologist. And now one of the things that I learned was that about two out of three patients, the patch testing doesn’t help but one out of about one out of three patients that I patch test, it actually makes a big difference.

But so I still left with two out of three that I had to figure out what to do. But the one out of three, what I quickly learned was my job is completely being a patient educator. So once I find out and again I’ll just use you as an example. Okay Abby is allergic to formaldehyde and Cookman appropriate bed Tane and fragrance. And now if I can teach you how to avoid those things, you will be cured and your life will be completely better and you will worship me for the rest of your life forever. And if I can’t teach you how to effectively avoid those things, nothing’s going to get you better ever. And so more than any other specialty in medicine, not just in dermatology, but medicine, the only treatment that I have available to me is patient education. And so I then got interested in how do you educate patients and in a very practical way.

So there’s, there’s, and what I mean, there’s one way of education that is sort of the same information for every patient and you just have to find the best, most efficient way to get it to people. So that might be diet for people with heart disease or you know, so the lifestyle modifications educating people about their kidney disease or whatever. The problem with what, with what I do as a patch tester is, again, it’s unique to every patient. So there are about 80 common things that people can become allergic to. So [inaudible] and if we say the average person is allergic to three of them, right? That means there’s basically 80 to the third power, different combinations, which is some massive, you know, hun, tens of hundreds of thousands of different combinations that are all unique. So there’s no like, Oh, I can have a handout that I’ll give to people because everybody’s totally different.

So it became, how do you do this? Mmm. And so, you know, as I did more research and we’re experimenting on patient education [inaudible], it really became interesting and how, how do you really do this? How do you educate people in an effective, efficient way? And one of the things that’s interesting is that, right? You would assume that talking to somebody face to face would be the most effective way to educate them. Totally wrong. Not effective at all. Right. Why is it not effective at all? Because the person that I’m talking to where it’s a very one directional, I’m the doctor, I know everything. You’re the patient, you don’t know anything. Listen to me, right? The patient is more thinking as I’m saying things. I’ve tried that already. It didn’t work for me, but I don’t want to interrupt them. He just said to do that.

Should I do this too? Like did he mean this or to put, they’re afraid to interrupt me. So they’re not even really listening. They’re more having this debate in their head conversation debate with me, but they’re just having their side of it, not mine. So they don’t really remember anything. One of the first things I learned was that if I have a patient watch a video of me saying say, educating them about some chemical they’re allergic to, they retain it much better than if I, if I had the exact same discussion face to face, I don’t remember it. If I haven’t watched a video of me saying the same thing, they remember it much better.

That’s so hilarious.

Okay.

You, I think you’re saying what every patient is thinking about that. Like there’s a meme out there where like, you know, patients feel more educated by Google than their doctors because like you mentioned, you’re the first dimension that like every dermatologist tells people to moisturize, not to take really, really hot showers. And like every patient has tried that and it hasn’t worked. So I just so thankful that you’re speaking what patients are wanting to hear.

Oh, and it’s, it’s part of what makes it fun for me because I actually like to say to patients, how many people have told you not to get hot showers? Oh, I think every dermatologist. Did you try it? Yeah. Did it help? No. Do you get hot showers now? Yes. Right. And it’s like, and they’re like, when are you going to tell me not to get hot showers? Say no, I’m going to tell you, get the hottest showers that you want. You know, if it feels good, great. One of the things I love to do with dermatologist, right, is ask them, well, why shouldn’t people get hot showers? And their answer is, well, that’s what my professors told me to tell people in residency. Okay, well why did they tell you that? I dunno. Does it seem like it helps your patients? Yes. Have you asked your patients?

No. Right? And so now why do we tell people not to get hot showers? So the science behind it is actually kind of interesting. Think about butter on a plate. Okay? So if you’re washing dishes tonight and you’ve got a plate that has butter on it, use the harshest soap that you want and try and wash that butter off in cold water. You can’t, right? On the other hand, turn the water to really hot. You don’t even need any soap. The butter just melts and runs away. The natural lipids in your skin. The natural protective oils are very similar to butter. So the hotter the water is, the easier it is to remove the oils from your skin. But if you’re using a pretty mild soap and you’re using some moisturizer afterwards, not that big of a deal. Right. The hot shower is, I’ve never had a patient in, in 20 years.

It’s like, Oh, I have bad eczema. And I was like, don’t take hot showers. And then they came back two months later, I was like, send them a gun. I stopped taking hot showers and I’m better. No, I never had a single patient tell me to help it. All right. So yeah. All right. So sorry. I digress. So that got me interested in patient education. So firstly that I learned was that face to face education isn’t that great. So then you would think, okay, well giving them written information, that’s real. The key is no written information. Totally worthless. [inaudible] Been shown over and over again. Written information does not improve, recall, does not improve sort of compliance. Most of the time they don’t even read it, right? They lose it. However, what a paper, what a piece of paper does is makes it reduces anxiety.

So people, if they just, if you tell them what to do, they are really nervous cause they’re gonna forget it and they are going to forget some of it. By far the best way to do it is a written material that you have personalized and made notes on it. Okay. Don’t listen to this part. This part right here is really important for you, blah, blah, blah. And as I was doing that over the years, it occurred to me, well, why am I writing on this stuff? It’d be quicker for me to just summarize what I’m thinking, what I wanted to do. And then if I do that, I can just copy and paste it into their chart and we don’t have to like make another note about what we told them to do because everything I told them is like literally in there already. And so that’s whenever I started.

You know, dictating in front of my patients and then immediately printing it, handing it to them when they walk out of the room. And that is actually made a pretty big difference for me in terms of outcomes. Because like I said, I also believe in negotiating it with patients. So I try and make it really clear. If you don’t think you can do what I’m telling you to do, tell me. Right. So whenever I say like, I want you to do this, I’m going to say, do you think you can do it? And like, yeah, no, that’s gonna you know, I don’t have time at night to, okay, great, then we’re not going to do that because I am, again, not a believer and so I’ll hear dermatologists say things like [inaudible], well, if the patients would just listen to us and put the moisturizer on twice a day, what I want to say is you do it, you put the moisturizer on twice a day, right?

How many heck no, they’re not doing it. It takes too long. Your clothes stick to you. The bleach baths [inaudible] leads faster. The worst thing in the world that ever came out in the world of dermatology. I think that now, do they occasionally help somebody? Yes. Right, but if, number one, if somebody told me I could live an extra 20 years, it’d be very healthy if I just started taking a 20 minute bath every night, I would be like, man, I’ll die when I’m 60 right. There’s no way that I’m going to take a bath every night. Just not my life is not going to permit that period, let alone if you told me to put bleach in there. Right. I understand the idea behind the bleach. I know it’s not going to stay in Burnaby irritating, but unless you have a long conversation very specifically about why the bleach is not going to be a problem, nobody’s going to go home and put leach in their bathtub.

Right. It just doesn’t it. So it, but it’s an example of does that work in kits? Yeah, probably works in kids because parents are used to putting their kids in the bath tub. Are you going to get many adults to get in the bathtub every night for 20 minutes? No, you are not. Right. And, but as the patient going to say, thank you for telling me that doctor’s Iris, but there was no way I’m going to do that. No patients want to, right? There’s an innate, it’s just like as a kid with your teacher, you want your teacher, you want to say yes to your teacher, you want your teacher to like you, you want to say yes to the doctor, you want the doctor to like you. So the patient’s sitting there and your room is thinking, well, it’s gonna be really hard to get a bath every night, but I guess I can, maybe I could make that work and, but it’s not going to happen, right?

They’re afraid to tell me that and they’re, they’re trying, but it’s just not going to happen. Right. And so I need to come up with, okay, what am I going to do? It’s different from getting in the bathtub every night because I know they’re not going to do that. Right? So it’s, it’s negotiating that with patients. And giving them permission to disagree with me and to tell me, no, I’m not, I, I can’t do that. I would love to do it, but I can’t. Right. [inaudible] yeah, it’s, it’s, it’s [inaudible] often it for a long time it frustrated me that other dermatologist in practice the way that I do, but I eventually realized it’s just there are so many people who need skin who need to see a dermatologist. Other rheumatologists just can’t. If they did, like I said, people would wait three years to see a dermatologist.

That’s a, that’s so hilarious. Like the way you put it. And I just love like your analogy and like everything that you said and, Mmm Hmm. Sorry. Yeah, I just love everything that you said and it’s, yeah, it’s, I think you just spoke what’s on every patient’s mind that usually the dermatologist is like, so kind of like in and out there off the authoritarian way where it’s like, you know, just listen to me. But like patients like you mentioned, just wanting to be listened to, like just want to be heard. And so I think it’s really rare to find like a dermatologist like you where you’ll actually, you know, listen to the patient, find what works for them. And like, I’m so glad that you actually take that time to listen to them and not just throw things at them and tell them to do it.

That’s it’s absolutely what it takes. The but you know, you, we talked a little bit before we started about, you know, how did I end up just sort of, I talked about why I started doing eczema. I’m going to tell a story that I have never told in public before. Which is why I became a dermatologist. I became a dermatologist. So I, I went to medical school thinking I was going to become a primary care doctor, but that’s what I wanted to do. Second year of medical school we were having a lecture from a kidney specialist and he talked about some very rare kidney problem where people would come in and they would say that there, that whenever they peed the urine was a funny color. And that happens all the time. It usually just means somebody has got a little bit of a urinary tract infection.

You give them some antibiotics and they’re fine, and he said, but you know, if you ever have somebody with this disease, they’ll come in and because you didn’t think about them individually as a patient and just said, well, the last 5,000 people I’ve had with this complaint, Oh, I had this and it worked. I’m going to do that in them. Well, when you see this patient with this rare disease, by the time they come back in two weeks, their kidneys will be completely dead and they’ll be on dialysis for the rest of their life and it’ll be your fault. And I was like, Oh my God. As a doctor, I’m not. I could make mistakes. Good Lord. I thought that doctors knew what was wrong with people and what to do for them. And it turns out doctors don’t. It is at best, an educated guests, sometimes more educated than not.

And I’m like, Oh my God, I can’t make educated guesses like, well, I don’t want to be a doctor. Good Lord. I don’t want to hurt people, but I’m already $50,000 in debt and I can’t drop out of medical schools. Now what am I going to do? Okay, what can I do that is the least like being a real doctor, I’ll be a dermatologist. Right? That’s why I became a dermatologist. Now once I got into dermatology, it turns out I’m [inaudible] much, this is isn’t good. This, this is going to sound bad. It’s not what I mean. But I, I, I function more like a real doctor than most dermatologists because I’m, I’m dealing with medications that have lots of toxicity you know, the same medications that an immunologist would use and, you know, dealing with really sick people. So it’s kind of a cruel joke on me that I decided to go into dermatology because I was worried that I didn’t want to be, have to take care of sick people.

And I decided to do the thing in dermatology where I’m taking care of the sixth, the sixth, well, some of the sixth people. But that’s why I became a group of colleges because I, in medical school I decided I didn’t want to be a real doctor, so I would become a dermatologist instead. Now, before anybody says anything, cause I do get this question sometimes when people ask me, what do you do for a living? And I say I’m a dermatologist, they’ll say, Oh, that’s kind of like being a doctor. Right? And I’ll be like, well actually it is really being a doctor. And, but so before anybody hears me say that and says, rheumatologists are real doctors, I know we’re real doctors. That’s just kind of me. I like to say things that make people go, wait, what did that guy talking about? I’d like to, that’s how I, that’s why I tend to try and get people engaged and interested is by making a slightly controversial statements. Sorry,

That’s so funny. But even as dermatologist, don’t you guys need like an extra, is it like four years more education?

So we we do the same medical school that everybody else does and then we do four years of additional dermatology specific training after medical school. So it’s a, you know say medical school residency just as long as everybody else’s. So we are just as much real doctors as everybody else’s.

Thanks for listening to part one of today’s episode. I hope that you’ll stay tuned for the next episode because my guests shares different supplements, different tips that can be very helpful for the skin as well. And if you love today’s episode or you just want to pass on a message to the dermatologist, feel free to message me. I can always pass on a message to him or even if you have questions, things like that. And I hope to see you in the next episode and feel free to connect with me on social media as well. I am at Exuma conquers on Instagram and Facebook and YouTube and I just can’t wait to have you hear the next episode. And also the next few episodes that we have lined up for you as well. Other episodes that are coming down the pipeline are things like how dental issues could possibly affect your skin. Also, tips for parents who have kids with the eczema, and I’ll also be sharing my story of healing and also going through really traumatic experiences with eczema. So thank you again for listening and hope to see you soon.

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